Kantonsspital Baselland SPECT/CT Imaging

05/03/2013

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Liestal ▲ Bruderholz ▲ Laufen

Klinik

Kantonsspital Baselland

SPECT/CT Imaging

Knee & Hip Prosthesis

Helmut Rasch, Michael T. Hirschmann

Institute of Radiology and Nuclear Medicine, Dept. Orthopaedic Surgery and Traumatology,

Kantonsspital Baselland-Bruderholz, Switzerland

[email protected]


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„ We greatly thank the following grantauthorities for their financial support of ourresearch.“

Flavio Forrer, Rolf Hügli, Niklaus F. Friederich, Faik K. Afifi, Enrique Testa, Milos Dordevic, Dominic Mathis, Stephan Schoen, Silvia Reichl, Anita Matt, Markus P. Arnold, Christopher Wagner

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Schedule

• Basics on Arthroplasty

• What is our SPECT/CT protocol?

• Why CT including extended Houndsfield scale?

• Cases

• Biomechanics – Why do we need it?

• Our experience- more to come….

• Conclusions

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Hip resurfacing not „en vogue“ anymore!Metal- on-metal bearing problem

Basics hip arthroplasty


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Short stem versus long stem


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Straight stem versus curved stemDifferent fixation conceptproximal, distal, combined


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Cemented versus uncemented stem► cemented: no ingrowth of bone, smooth surface

► cemented: ingrowth of bone; rotation stability due to rectangular shape; roughened surface


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uncementedscrew cup versus press-fitouter cup metal, inlay made of polyethylen, ceramic or metal

cementedoften polyethylen



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Unicondylar versus bicondylar knee arthroplasty

Basics knee arthroplasty

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„Unconstrained“ versus „constrained“



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„Unconstrained“ – „fixed versus mobile bearing“


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cemented hybriduncemented


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Examination protocoll – Scintigraphy & SPECT/CT

early 15min late ~40min

0 2‐3 h

• „perfusion phase“• „Bloodpool –phase“2 planes

• Whole body ap / pa• SPECT • and low dose CT

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3mm slices femoral head

0.7mm slices knee

3mm slices ankle joint

Modified

Imperial CT

protocol

(Henckel et al.

JBJS Br 2006

&

Hirschmann

et al. 2011

BMC Medical

Imaging)

4D-SPECT/CT Protocol


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SPECT/CT protocol – „biomechanical aquisition“

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CT image quality – importance of extended scale

1200HU 4000 HU

6500 HU 14000 HU


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Extended scale necessary? - YES

Up to 14000 HU

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Case examples

• The “typical“ case

• Uptake – always pathological?

• No Uptake – everything OK?

• Hypersensitivity reaction

• Infection

• Biomechanical knowledge – why we need it


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The “typical“ case

recurrent weight bearing, activity related pain 10 yrs after THA

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recurrent weight bearing, activity related pain 10 yrsafter THA



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Does increased uptake always indicate a pathology?

Referred from GP for knee pain


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Cortical hypertrophy at distal fixation zone; ectopic ossificationRasch H, Hirschmann M, Huegli R. SPECT-CT - Prospects in Joint Imaging and Diagnostic Follow up after Arthroplasty Der Nuklearmediziner. 2012; 35 (03) :154-60. DOI http://dx.doi.org/ 10.1055/s-0032-1321822; Georg Thieme Verlag KG

Does increased uptake always indicate a pathology?

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No periprosthetic Uptake – everything OK?

Past right sided THA 1999; activity related pain in righthip


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No Uptake – everything OK?

Rasch H, Hirschmann M, Huegli R. SPECT-CT - Prospects in Joint Imaging and Diagnostic Follow up after Arthroplasty Der Nuklearmediziner. 2012; 35 (03) :154-60. DOI http://dx.doi.org/ 10.1055/s-0032-1321822; Georg Thieme Verlag KG

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Hypersensitivity reaction?

Past UKA 06/2011, past TKA 01/2012, burningsensation and pain, extension deficit


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Infection – 3 Phase scintigraphy

TKR 06/2005; Arthroscopy with biopsy 12/2011+ 10/2012; unexplained knee pain; suspicion of low grade infection

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Infection – SPECT/CT


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Infection – anti-granulocyte scintigraphy

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„A special case at the end“

TKA right 17.02.2011; past arthroscopic arthrolysis 3/2012persistent pain, indication for secondary patellar resurfacing


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„A special case at the end“

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Only patellar hyperpression?

Did you know what was wrong?

Look more closely!„A special case at the end“


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Biomechanics – Do we need it?

UKA 3 years ago, unexplained anterior knee pain

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Biomechanics – Do we need?

No patella problem - BUT.......


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Femoral alignment Combined alignment

UKA rotation alignment (internal-external)

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TKA 2008; patellar resurfacing 2010; anterior knee pain

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6° Int 2° ant


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Biomechanics – own results!

• SPECT/CT tracer uptake related to TKA component position!• Unpublished data 200 painful TKA!

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• Distal versus proximal or

combined stem fixation

• Orientation and position of THR

• varus-valgus stem leads to

increased SPECT/CT distally


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Hirschmann MT et al.: A novel standardized algorithm for evaluating patients with painful TKA using combined single photon emission tomography and conventional computerized tomography; Knee Surg Sports Traumatol Arthrosc. 2010 Jul;18(7):939-44.

Combination of SPECT/CT tracer uptake and TKRcomponent position: new era of imaging!

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Biomechanics – software tool


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3D volumetric quantification and localization using

customised software

Hirschmann MT et al., BMC Medical Imaging 2012

Assessment of tracer uptake distribution and intentity

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Femoral alignment Tibial alignment

Varus-Valgus alignment (coronal)


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Sagittal alignment (flexion-extension)

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Rotational alignment (internal-external)


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NEW: biomechanical analysis in true 3-D

Biomechanical measurement of THA

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• Usage of true 3 D Landmarks

• Reproducible measurements

• Possibility to differentiate and correlate uptake patterns with biomechan

Biomechanical measurement of THA


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Conclusion

Mechanics and structure and biology

Mechanics

• mechanical alignment

• anatomical alignment

Structure

• bone

• Muscles

• Tendons

• Ligaments

Biology/Metabolism

SPECT + CT = SPECT/CT

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Questions you should ask to yoursurgeon

Age of implant

Type, design of prosthesis

Mode of fixation

Site of pain

Mechanical alignment

Loading pattern


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Tips from our experience Reducing scanning time

Radiation dose reduction

Improving image quality

- Extended CT scale

- Cut-out bladder uptake

Relative component position (e.g. bearing partners)

SPECT/CT can be helpful as early as 6mths after surgery

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Take home messages

• Use all information – metabolic, biomechnical and morphological information to obtain a correct diagnosis

• Prosthesis loosening does not always show an uptake

• Not every periprosthetic uptake is loosening or infection – look for biomechanics

• For correct intepretation you have to know the biomechanics of the implanted type of prosthesis (e.g. fixation of THA proximal or distal)

Talk to your surgeon – interdisciplinary approach


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Documents

Kantonsspital Baselland SPECT/CT Imaging